death

All quiet on the transplant front again. Seems like as soon as I come near the service the operations disappear.

Which leaves time to study for the ABSITE, a good thing since the test is coming up in. . . 8 days. I got to the neurosurgery part of the review book, and had a flashback to my neurosurgery rotation.

It was far enough in to the month that I was holding the call pager by myself most days. I got called to see a lady in the ER. She’d had a headache for a few days, but that day it was much worse, and her son had finally forced her to come to the ER. Her history of severe, poorly controlled hypertension was a red flag, and the ER doctors got a CT scan. By the time it was done, and they had recognized the subarachnoid hemorrhage, her mental status was deteriorating to the point that, while still fairly alert, she could no longer answer questions coherently. I didn’t waste much time on exam, just verified that her pupils were still equal and reactive, and there were no other gross neurological deficits yet (neurosurgery physical exam is the most abrupt and pointed of any specialty), then called the resident. He concluded that her worsening symptoms were due to a still-active aneurysm, and arranged for her to be taken to radiology for an emergent cerebral angiogram and coiling of the aneurysm. I saw her off, then tried to tackle some of the other pages that had been accumulating (hypotensive post-op patient; tachypneic patient failing a vent wean; rising ICP; hyponatremia in a trauma patient).

About half an hour later I got a stat page from radiology: “Your patient just had a bradycardic arrest on the table, maybe you should come down here.” I asked the nurse to please page my resident as he was the only really useful person, and then ran down the stairs.

I arrived (with the resident soon on my heels) to find that the report was very slightly exaggerated. She hadn’t completely arrested, just become so bradycardic that there had been several 20-second pauses between heartbeats. That had improved with atropine, and she was now awake. So awake, in fact, that she was insisting on leaving AMA.

Which posed a problem, since her vital signs were a classic case of Cushing’s triad, found in impending brain stem herniation: bradycardia, hypertension, and slow respirations. Well, actually, she was breathing just fine, since she was loudly insisting that we let go of her, give her clothes back, and let her leave.

The resident announced that he needed to put in a ventriculostomy drain now – right there, in the middle of the angio suite. He started finding the supplies – some of which had to be brought down from the neuro ICU. I was left to deal with the matter of consent. The patient herself was very dramatically not consenting. By now, it was taking the efforts of two nurses to keep her lying down (which of course wasn’t doing any good for her blood pressure or her intracranial pressure, which was what we intended to relieve by placing a drain). Her son, whom we knew to be somewhere in the hospital, had disappeared: either he was trying to get a bite of lunch, or the move to the maze in the depths of the radiology department had lost him. So when the supplies were assembled, we decided to proceed with the drain as an emergent procedure – no consent required.

Despite all of us knowing quite well that the patient’s protests were further evidence of altered mental status and injury from the blood now surrounding her brain, it was no fun to perform an invasive procedure on patient who spent the entire time protesting that we were kidnapping and abusing her, and who had to be held down by several staff members. Once the drain was placed, we ended up intubating her right there as well, as her level of consciousness continued to decline.

So by the time her son caught up with us, in the neuro ICU, we had the job of explaining that his mother had gotten significantly worse, and was now on a ventilator.

It was all downhill from there. Everything that can go wrong with subarachnoids went wrong with her: her ICP stayed up despite all measures to lower it; she had surgery to remove the aneurysm, but with no improvement; she remained in persistent vasospasm, despite every single treatment in the book being tried; she developed diabetes insipidus (seen in brain injured-patients when the hypothalamus stops producing anti-diuretic hormone, needed for the kidney to concentrate urine). After two weeks in the ICU, she died. So the last her son saw of her, conscious, was in the ER; and the last time any of us had talked to her had been while we were wrestling with her in radiology.

That’s why I hate dealing with subarachnoid hemorrhages, and I could never imagine being a neurosurgeon. Within twenty minutes she went from a pleasant lady with a headache to being delirious, then intubated and critically ill; and nothing we did could help at all.

A few hours into a busy morning – the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do – I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed.

So my seeing the patient and writing a formal consult was going to contribute absolutely nothing to the patient’s care or to my team’s knowledge of her; but it had to be written.

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise.

She was polite, pleasant, and a very coherent historian (first clue; real seekers try to muddy the waters). She was able to tell me all the studies that had been done, and gave me a timeline of her symptoms and the path to the final diagnosis.

I asked how long she’d been on disability, and all of a sudden she started talking. She’d been injured a few years before, but had kept busy up till last month taking care of her father, whose health had declined precipitously. Last month he died at home.

I didn’t have to say anything at all; she just wanted someone to listen. She told me about her mother’s poor health and inability to care for her husband, about how painful it was to watch her father getting continually worse. She told me about how he joined the army right after Pearl Harbor, flew several bombing missions, and was eventually interned in Switzerland, then came back to get married and start a family.

There was a lot more – his death had hit the family hard, and it sounded like the siblings weren’t relating to each other well now – but I wasn’t looking for holes in the story any more. No slacker takes disability, then works 24/7 caring for a dying parent. Most healthy people don’t do that much.

At the end of that talk, I understand why psychiatrists don’t believe in physical exam. After that much sharing, it’s rather anticlimactic to ask if you can listen to the patient’s lungs.

That’s such a horrible feeling. I can’t help him. I can’t stop the disease, I can’t change anything anymore. It’s too late.

At that point, the thought arises, if I can’t cure him, at least maybe I could make this quicker, easier for him and his family.

I never thought I’d understand (dare I say sympathize with) that idea.

I understood today, finally, how doctors, whose purpose is to heal, can end up wanting to kill (because that’s what euthanasia is, in the final analysis). I wanted to do something, anything, for this man; and if I couldn’t fix him, that left only one thing.

The problem is that I’m not God. There’s a very old joke about the difference between God and the surgeons; and I think death is his way of reminding us humans of our place in the world. Death is not under our control. It’s not a thing that we can order around, or organize, or turn off and on at our whim.

Life and death belong to God. He gives life, and he controls its end. The time of death does not belong to us. That’s our human arrogance talking, to think we can control every aspect of our lives, right down to death itself.

So I had to let go. That man was God’s creation. God let me care for him for a while; but ultimately I and my colleagues were never the ones in control. As the psalmist says, “Man returns to dust, and his spirit returns to his Maker.”

I must have been looking disturbed. A couple of people, including the chief resident, asked me how I was handling the one patient’s death, and then stood still to listen to my answer. That’s the closest to those ‘debriefing’ things I’ve ever gotten (and I hope not to get any closer; surgeons don’t do well talking about feelings involuntarily). Just to have them ask was all I needed, and I told them I was fine. After all, in a way, when someone’s been deathly ill in the ICU for weeks, it’s a relief all around when they go. I feel kind of guilty, to be this relieved, but after all, they’re probably relieved to be done with the whole thing too. Except I’m fairly certain they’re in hell now (lots of Buddhist paraphernalia); in which case none of this is very good. . .

One of the patients who died recently had an autopsy, and I felt like I ought to go. I would be less of a good doctor and surgeon if I neglected anything relating to my patient, even now that she’s dead; but I also felt like a very bad person, to be semi-comfortable with seeing a person I’d known cut up in pieces. In the end, I got called away before matters had progressed very far; which was just fine with me, and I’ll wait to see the report in a week. (And the pathology residents: I can’t even imagine having that job. I can kind of picture what it would be like to do ER, or medicine, or radiology. But pathology is not just a different species, it’s a couple genuses [geni?] away. How can you be a doctor and not touch live things?)

A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” – but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all.

Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so businesslike, not high on my list. But you have to. And then there were all the other patients who needed to be paid attention to, and just because one person died is no reason to go neglecting or ignoring the others. So I went and did all the appropriate procedures, and they weren’t much fun. A needle here or there. . . but I couldn’t save the one guy who really needed help.

I don’t know which was worse, talking a family through their loved one’s death, when I’d only seen the patient for five minutes beforehand, and we only had an hour to work through it (like yesterday), or handling it after a month of struggling together, like today. Strangers or long-term acquaintances, it doesn’t get easier.

I’ve been calculating all month, and I work out my prospects for the rest of the year as follows: nearly all the second year rotations are unpleasant, and nearly all of them last for more than one month. So the chances of September being even more miserable than August are at least 70%. This is not good. Without hope, things fall apart.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

My shoulders are sore from doing compressions, and my hands ache from holding the seal around a face for ventilation, or squeezing a bag of saline to make it run faster. Three codes in two days – far too many.

The last one, I just went up to the floor to check on a patient I’d transferred out of the unit, and they called a code down the hall. I had to be one of the closest people, so I thought I’d go check. It was real. The patient got intubated, and we had a line in, and it felt as though things were under control. Airway, rhythm on the monitor. . . so why was the patient so blue? I found myself doing compressions, and trying to persuade everyone else in the room that I really had not felt a pulse, and the rhythm on the monitor was nothing more than PEA (pulseless electrical activity). . . It’s hard to talk while doing compressions properly, but it wasn’t hard to prove. . . Not much good in the end. (Note to self, ekg leads aren’t enough, you need pulse ox and blood pressure too; and just because the patient had a pulse two minutes ago doesn’t mean they still do.)

When I was younger (a whole year ago), I used to go to these things and be all quivery and excited because I thought we might save somebody’s life. Now, like the rest of the senior residents and attendings, I don’t worry too much, because I know it’s not going to work anyway. Even if by some chance we got a circulating rhythm back, the patient will, 95 times out of 100, die in the ICU anyway.

I woke up this morning and I couldn’t figure out why my shoulders ached so much. It took me a couple of hours to even remember the code the day before, and connect my frantic compressions to the current situation. It was several hours later that I remembered the code before that, which was why my hands hurt. Ok, I’ve got it all straight; I’m ready for the next one.

Disclaimer

Patients described here are purely fictitious, and any resemblance to actual persons is entirely coincidental. The theology, on the other hand, is very much for real.
Please see a real live doctor for any personal medical concerns.